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PEG tubes and Dementia
Percutaneous endoscopic gastorstomy (PEG) tubes have increased in usage to provide patients with nutrition. However, PEG tubes have not shown to benefit patients with advanced dementia. PEGs have not shown to improve nutrition, improve survival, reduce pressure sore risk, reduce pneumonia rates, improve quality of life or reduce aspiration (Finucane T, Christmas C, &Travis, K., 1999).
Why don’t PEG tubes improve nutrition/hydration in advanced dementia patients?
Nutritional parameters have not shown to improve with PEG tubes even with adequate formula. Patients with advanced dementia have cachexia due largely from inflammatory cytokines that are unimproved by nurition.
Why don’t PEG tubes improve survival in advanced dementia patients?
Feeding tube placement is a surgical procedure. Although it is a simple procedure, all procedures come with risks. Mortality during PEG placement ranges from 0-2%. Mortality rates (not restricted to patients with dementia only) were 2-27% at 30 days and 50% or more at 1 year. Median survival rate was 7.5 months (Finucane T, Christmas C, &Travis, K., 1999).
Complications of PEG tubes include tube migration, gastric prolapse, prolonged ileus, necrotizing fascitis, diarrhea, nausea, tube malfunction, aspiration, peritonitis, abdominal abscess, bowel obstruction, vomiting, death, pneumonia.
Why don’t PEG tubes improve pressure ulcers?
Retrospective studies found an increased risk or no benefit associated with tube feeding and pressure ulcers. Another study with a 6-month follow up reported that tube feeding was not associated with healing of preexisting pressure sores or protection of new pressure sores.
This may be due to increased restraint use with patients with PEG tubes causing limited movement to be off the pressure sore.
Why don’t PEG tubes reduce aspiration risk or pneumonia rates in advanced dementia patients?
PEG tubes actually increase the risk of aspiration pneumonia. It is one of the most common causes of death after PEG placement. This may be due to increased gastroesophageal reflux or from oropharyngeal colonization. (Finucane TE, Bynum JPW, 1996). PEGs may reduce lower esophageal sphincter pressure and increase the risk of gastroesophageal reflux. A nonrandomized, prospective study showed that orally fed patients with oropharyngeal dysphagia had significantly fewer major aspiration events than those fed by tube.
Why don’t PEG tubes improve quality of life in advanced dementia patients?
Patients with advanced dementia are likely unable to communicate his or her wants/needs. Therefore comfort can only be based on inference. Terminally ill patients with anorexia with cancer/stroke, few experienced hunger or thirst. Of those who did, relief was achieved with small amounts of food and fluids.
Tube fed patients would be denied the pleasure of eating or made uncomfortable to the tube and frequent repositioning. Increased restraint use occurs with advanced dementia patients with PEG tubes.
Are we starving the patient if we do not provide artificial nutrition/hydration?
The majority of patients who stop eating do not experience hunger or are only hungry initially. Terminal anorexia and dehydration may actually benefit the patient by inducing ketosis, uremia, and endorphin release.
Speech-language pathologists are important in helping families make decisions concerning PEG placement. When a patient begins having difficulty with eating or dirnking, make them aware and let them know their decisions for the future. The patient can then be prepared and have their wishes written down.
Patient education form: to help families decide if a PEG tube would benefit their loved one:
Tube Feeding Decisions for People with Advanced Dementia
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References:
Finucane, T., Christmas, C. & ravis, K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA, 1999;282:1365-1370.
Finucane TE, Bynum JPW. Use of tube feeding ot prevent aspiration pneumonia. Lancet, 1996; 348:1421-1424.
Related posts:
- Does Thickening Liquids Work to Prevent Aspiration in Patients with Dementia?
- SLP role in Decannulation of Tracheostomy Tubes
- Blom Tracheostomy Tube
- Aspiration Pneumonia or Aspiration Pneumonitis
- Dysphagia and Dehydration
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